Post-Concussion Syndrome

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1 Post-Concussion Syndrome Anatomy of the injury: The brain is a soft delicate structure encased in our skull, which protects it from external damage. It is suspended within the skull in a liquid called cerebral spinal fluid. This liquid serves to cushion the brain from damage. A concussion is a traumatic brain injury from a jolt to the head or a bell ringer that results in the brain quickly shifting and pulling on the structures within the skull. An external impact is not always necessary to produce a concussive force. This force can also result from the brain impacting the inside of the skull as well as the straining of the tissues that support the brain when the body stops too quickly, like in an auto accident. Regardless of the type of impact, the injury causes a chemical change within the brain that alters its ability to function, even though structural damage is not always present. For this reason, concussions are often not evident on diagnostic tests, like MRIs or CT scan imaging. Our nerves within the brain are extremely sensitive to this chemical change. When these changes occur our nerves have difficulty regulating some of our body s basic functions, such as keeping our heart rate stable during exercise. This chemical change within the nerves also disrupts our body s coordination and balance. Symptoms (what your child will feel) - Headaches - Fogginess - Dizziness - Vision changes - Difficulty concentrating/remembering - Ringing in the ears - Loss of balance - Fatigue/Drowsiness - Sensitivity to light/noise - Nausea/Vomiting Signs (what you will see in your child) - Loss of balance - Forgetfulness/amnesia - Acting disoriented - Dazed/confused - Forgetting game scores or rules - Inappropriate emotions - Personality changes - Slow to respond - Poor coordination - Loss of consciousness (only seen 10% of the time) Page 1

2 After your child has been diagnosed with a concussion, the first step in treatment is REST! The brain is extremely sensitive to further damage in the time following the concussion. This damage doesn t have to be the result of a physical injury. Daily stress and overuse of the brain can actually take away the focus on healing and recovery. The most important course of treatment is to rest the brain as much as possible, both physically (sports/activities) and cognitively (school). This sometimes means limiting school, sports, TV, computer, cell phones and loud or crowded places. Recovery time for each child is unique for each case. As symptoms start to subside, your doctor can provide help in determining when to return to cognitive and physical activity. Doctors Visits If your child continues to experience symptoms beyond two weeks, they are recommended to see their pediatrician or a concussion specialist. These visits are there to assist you and your child with any medical management that may help their recovery as well with any academic or athletic accommodations that are needed. In the Commonwealth of Massachusetts if your child is suspected to have a concussion, they will not be able to return to athletics without written medical clearance by a certified physician. ImPACT Testing After your child s injury, they may be asked to take a test to assess their neurocognitive function (thinking ability). This test is administered and interpreted by trained professionals only. The results can be used to measure progress, and will help determine your child s return to cognitive and physical activity. What is Post-Concussion Syndrome? Many concussions and their symptoms resolve within 7-10 days with proper rest. More severe cases of concussion do carry the possibility that post-concussion syndrome can arise. Post-concussion syndrome occurs when the brain is having difficulty healing and returning to its prior level of function. This normally manifests as three or more symptoms lasting longer than four weeks. options frequently include prolonged rest, academic accommodations, medications and physical therapy. Rehabilitation Philosophy There is currently no treatment that will accelerate your child s recovery from a concussion. However, rehabilitation can treat secondary injuries such as vertigo, neck muscle strains, balance dysfunction, and abnormal eye movements that stress the brain and slow its recovery time. By treating these injuries, rehabilitation puts your child s brain in its most optimal healing environment. One of the goals of post-concussion rehabilitation is to increase blood flow and nutrients to the brain during recovery. This will aide in healing, higher cognitive functioning, and help increase your child s tolerance to exercise. Research done under Dr. John Leddy indicate that closely monitored, progressive increases in physical activity can in fact be performed safely to assist with decreasing these lingering symptoms. Your child s physical therapist will design and assist in administering an individualized exercise plan, which will re-educate the brain to tolerate exercise and eventually return to athletics safely. Page 2

3 Rehabilitation **The following is an outlined progression for rehab. Timetables are approximate and advancement from phase to phase as well as specific exercises performed should be based on each individual patient s case and sound clinical judgment by the rehab professional. ** Pre-Rehab Phase: Goals Protect from further damage. Decrease acute symptoms. Promote adequate rest. Precautions No return to activity until cleared by MD. Decrease physical and cognitive stimuli. Guidelines As symptoms start to subside, your doctor can provide help in determining when to return to cognitive and physical activity Phase 1: Benign Paroxysmal Positional Vertigo (BPPV) (if applicable): Dizziness is a significant symptom lasting for longer than two weeks. Usually lasting during short duration from 5-30 seconds. P Patient reports dizziness or room spinning sensation. Tests: Hallpike-Dix Test Roll Test : Canalith Repositioning Technique Page 3

4 Cervical/Thoracic Strain, Cervicogenic Headaches (if applicable): Consistent cervical pain at rest or with movement Palpated tenderness through cervical and thoracic musculature Palpated tenderness at suboccipital musculature with provocation of headache. Over the head headaches with prolonged upright activities. Tests: Rule out peripheral neurological involvement; warrants a return to MD Sub-occupital release. Cervical PROM/stretching. Soft tissue mobilization, myofascial release. Initiate postural strengthening Cervical isometrics Oculomotor Dysfunction(if applicable): Symptoms of double vision, difficulty ready and loss of balance. Tests Cranial Nerve Testing (II, III, IV, VI, VII) VOR I, II, Cancellation Convergence, Divergence Saccades Cooksey- Cawthorne Exercises. Habituation exercises Gaze stabilization exercises in various positions. Visual scanning exercises in various positions. Balance Dysfunction (if applicable): Unable to walk a straight line with normal or narrow BOS Frequent LOB reported. Increased postural sway Tests Romberg Test BESS (Balance Error Scoring System) test Postural Perturbations Righting reactions assessment Coordination assessment Progressive balance training Core strengthening Postural strengthening Initiate Light Phase I Exercise: No symptoms greater the 3/6 (according to Acute Concussion Evaluation from UPMC) Page 4

5 Progressive decrease in symptoms Increased baseline HR Tests Exertional Assessment Initiate light cardiovascular exercise (30-40% Max HR) Limited positional change and head movement Static balance exercises Minimal stimuli in exercise environment Phase II Exercise Progressive decrease in symptoms at rest < 3/6 (according to Acute Concussion Evaluation from UPMC) Symptoms continue to be provoked by exercise Noted improvement in all applicable phase I symptoms Progress cardiovascular exercise to 40-60% Max HR Initiate positional changes with head movement Progress to dynamic balance exercises Continue phase I treatment as needed Phase III Exercise No symptoms at rest or during activity Decreasing baseline HR Progress cardiovascular exercise with 60-80% Max HR Progress postural changes with cardiovascular exertion Progress to dynamic balance exercises with cardiovascular exertion Increase environment stimuli Initiate multi-step exercises Phase IV (Functional) Exercise Progress cardiovascular exercise to 80-90% Max HR Non-contact sport-specific training Increase coordination and cardiovascular training Increase reactionary neuromuscular re-education Increase dynamic balance exercises Phase V (Return to Play) Exercise: Cardiovascular exercise to 100% Max HR Progress to return to play contact exercises Page 5

6 PHASE SYMPTOMS PLAN OF CARE Phase I- Benign Paroxysmal Positional Vertigo (BPPV) Phase I- cervical/thoracic strain, cervicogenic headaches -Dizziness is a significant symptom lasting for longer than two weeks. -Usually lasting during short duration from 5-30 seconds. P -Patient experiencing room spinning sensation. -Consistent cervical pain at rest or with movement -Palpated tenderness through cervical and thoracic musculature -Palpated tenderness at suboccipital musculature with provocation of headache. - Over the head headaches with prolonged upright activities. Test: Hallpike-Dix, Roll Test : Canalith Repositioning Techniques - Sub-occupital release. - Cervical PROM/stretching. - Soft tissue mobilization, myofascial release. - Initiate postural strengthening - Initiate cervical Isometrics Phase I- Oculomotor Dysfunction Phase I- Balance Dysfunction -Symptoms of double vision, difficulty ready and loss of balance. - Unable to walk a straight line with normal or narrow BOS - Frequent LOB reported. - Increased postural sway Tests: Cranial Nerve Testing (II, III, IV, VI, VII),VOR I, II, Cancellation, Convergence, Divergence, Saccades : Cooksey- Cawthorne Exercises, Habituation exercises, Gaze stabilization exercises in various positions, Visual scanning exercises in various positions. Tests: Romberg Test, BESS (Balance Error Scoring System) test, Postural Perturbations, Righting reactions assessment, Coordination assessment : Progressive balance training, Core strengthening, Postural strengthening Phase I- Initiate light exercise -No symptoms greater the 3/6 (according to Acute Concussion Evaluation from UPMC) -Progressive decrease in symptoms -Increased baseline HR Tests: Exertional Assessment : Initiate light cardiovascular exercise (30-40% Max HR), Limited positional change and head movement, static balance exercises, minimal stimuli in exercise environment Page 6

7 Phase II Exercise Phase III- Exercise Phase IV- Functional Exercise Phase V- Return to Play Exercise - Progressive decrease in symptoms at rest < 3/6 (according to Acute Concussion Evaluation from UPMC) - Symptoms continue to be provoked by exercise - Noted improvement in all applicable phase I symptoms - No symptoms at rest or during activity - Decreasing baseline HR - No symptoms at rest or during activity - Decreasing baseline HR - No symptoms at rest or during activity - Decreasing baseline HR : Progress cardiovascular exercise to 40-60% Max HR, Initiate positional changes with head movement Progress to dynamic balance exercises, Continue phase I treatment as needed : Progress cardiovascular exercise with 60-80% Max HR, Progress postural changes with cardiovascular exertion, Progress to dynamic balance exercises with cardiovascular exertion, Increase environment stimuli, Initiate multi-step exercises : Progress cardiovascular exercise to 80-90% Max HR, Non-contact sportspecific training, Increase coordination and cardiovascular training, Increase reactionary neuromuscular re-education Increase dynamic balance exercises : Cardiovascular exercise to 100% Max HR, Progress to return to play contact exercises *Reviewed by Janet Kent, MD Page 7

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